Acute leukemias are characterized by the proliferation of immature undifferentiated cells of the hematopoietic system, and chronic leukemias by excessive growth and expansion of mature, differentiated cells. There are 28,500 new cases of leukemia diagnosed each year, usually evenly divided between the acute and chronic forms. Four major categories are:

• Acute nonlymphocytic leukemia (ANLL, also known as acute myelocytic leukemia [AML]); variants include FAB classifications M1 to M7.
• Acute lymphocytic leukemia (ALL); variants include FAB classifications L1 to L3. ALL comprises 90% of the childhood leukemias.
• Chronic myelocytic leukemia (CML) occurs in three stages: chronic, accelerated, and acute.
• Chronic lymphocytic leukemia (CLL); variants include prolymphocytic leukemia (PLL), hairy cell leukemia (HCL), T-cell CLL, and T-cell leukemia/lymphoma, although 95% of CLL patients have a B-cell disorder.

Most causes of leukemia are unknown; however, there is a known association of ALL and AML to excessive exposure to ionizing radiation and occupational exposures to benzene. T-cell leukemia/lymphoma is linked to a viral infection with T-cell lymphotrophic virus-I (HTLV-I). As many as 20% of cases of AML may be due to the chemical mutagens of cigarettes. There may be a significant familial component to some leukemias.

• Increasing age
• Genetic diseases (e.g., Fanconi's anemia, Down syndrome)
• Acquired diseases (e.g., Hodgkin's disease, polycythemia vera)
• First-degree relative with leukemia
• Excessive exposure to ionizing radiation
• Chemical exposure (e.g., benzene)
• Drugs (e.g., alkylating agents: melphalan, cyclophosphamide; also chloramphenicol, phenylbutazone)
• Cytogenetic abnormalities (e.g., Philadelphia (Ph) chromosome, ataxia telangiectasis)
• Cigarette smoking

• Fatigue
• Fever
• Pallor
• Weight loss
• Shortness of breath
• Easy bruisability
• Bleeding (e.g., hemorrhage, petechiae)
• Repeated infections
• Bone pain
• Abdominal pain

• Severe folate or B₁₂ deficiencies
• Leukemoid reaction (e.g., tuberculosis or other infection)
• Multiple myeloma
• Polycythemia vera
• Aplastic and refractory anemia
• Thrombocythemia
• Myelofibrosis
• Immune-mediated neutropenia (e.g., systemic lupus erythematosus, AIDS)
• Steroid therapy

Patients with acute leukemias are likely to present with fever, pallor, petechiae, ecchymoses, lymphadenopathy, splenomegaly, and hepatomegaly. Patients with advanced chronic leukemia may present with fever, bone pain, weight loss, elevated white blood cell (WBC) count, basophilia, and increased alkaline phosphatase.

Laboratory data are likely to detect anemia (decreased erythrocytes), thrombocytopenia (decreased platelets), neutropenia (decreased neutrophilic leukocytes), and leukocytosis (increased leukocytes).

• Complete blood count and differential
• Serum chemistries and electrolytes
• Human leukocyte antigen typing
• Coagulation profile and blood typing
• Peripheral blood smear (e.g., Wright's stain), to distinguish between acute and chronic leukemia
• Bone marrow aspirate and biopsy, to diagnose and classify the type of leukemia
• Histochemical stains (e.g., periodic acid-Schiff)
• Immunologic marker studies, to detect common acute lymphocytic leukemia antigen (CALLA)
• Cytogenetic studies and cellular phenotyping with monoclonal antibodies

Acute leukemia: leukemic cells do not differentiate completely and become an expanding mass of immature cells (30% of cells) introduced into the bloodstream from the bone marrow and infiltrating organs such as the spleen, liver, or lymph nodes.

Chronic leukemia: there is an excess production of mature-appearing granulocytes and platelets (i.e., the WBC count is two to four times normal), often infiltrating the spleen and liver. Most patients (94%) demonstrate the Ph chromosome.

• Electron microscopy, to demonstrate "hairy" cellular projections of hairy cell leukemia
• Ultrasonography, to diagnose renal complications and organomegaly
• Chest film, to obtain baseline film, show mediastinal masses, and reveal leukemic infiltration of certain organs

Lumbar puncture, to diagnose meningeal leukemia

While chemotherapy, antibiotics, transfusion of blood products, and allogeneic bone marrow transplantation (BMT) have led to improved survival and, in some cases, to improved chance of cure, the leukemias remain severe and often fatal diseases.

• For ALL: vincristine (2 mg weekly); prednisone (60 mg/m²/day for four weeks); daunorubicin (45 mg/m²/day) for first three days; L-asparaginase (6,000 U/m²/day) on days 17 to 28 for the four-week program; good response is seen in 75% of patients
• For AML: cytarabine (100 mg/m²/day for seven days) with daunorubicin (45/mg/m² for three days)
• For CML: busulfan (4 to 6 mg/day) or hydroxyurea (1 to 2 g/day), to lower WBC count; interferon-alpha (5 X 106 U/m²/day, to induce remission. Other agents include 6-mercaptopurine, 6-thioguanine, and dibromomannitol.
• For CLL: chlorambucil (6 to 14 mg/day) with prednisone (30 to 60 mg/m²/day for five to seven day/month) or cyclophosphamide (100 to 200 mg/day or 1 to 1.5 g every three weeks)
• For CLL variants: hairy cell leukemia: interferon-alpha (2 X 106 U/m² three times weekly for one to two years) and the purine analogs 2-deoxycoformycin and 2-chlordeoxyadenosine (2-CDA); T-CLL, PLL, and T-CLL associated with HTLV-I do not respond to therapy
• Methotrexate (10 to 15 mg) or ara-C (100 mg) twice weekly, to treat CNS leukemia
• Hydroxyurea and busulfan, to control WBCs and platelets
• Allopurinol (300 to 500 mg/m²/day) to treat hyperuricemia and prevent urate nephropathy
• Antibiotics to treat infections

• Lumbar puncture, to detect CNS leukemia
• Bone marrow transplantation (BMT), to induce long-term remissions (allogenic or autologous in first remission for ANLL if matching sibling is available or if at high risk for ALL)
• Splenectomy (largely replaced with systemic agents but reserved for CML patients who respond to chemotherapy but still have symptomatic splenomegaly and for some patients with hairy cell leukemia)

Nutritional and herbal therapies may be helpful in slowing the progression of leukemia as well as lessening the severity of the disease process. In addition, complementary therapies may reduce side effects and sequelae of conventional treatments.

• Include nutrient-dense foods that are high in antioxidants. Dark berries, orange and yellow vegetables, and dark leafy greens are high in compounds that are cancer protective. Fresh vegetable juices containing wheatgrass, beets, romaine lettuce, parsley, and cucumber are easily assimilated, highly concentrated antioxidants.
• Vitamin A (25,000 IU/day), vitamin E (800 IU/day), vitamin C (3 to 6 g/day), and selenium (200 to 400 mcg/day) have antioxidant activity and may decrease side effects of chemotherapy and radiation.
• Vitamin D (400 to 800 IU/day) may help promote differentiation of cells.
• B-complex (50 to 100 mg/day) with additional B₁₂ (1,200 mcg/day) and folic acid (800 mcg/day) for anemia.

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose for teas is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes).

Herbal treatment is focused on supporting the lymphatic system, the spleen, bone marrow, and liver. Many of these herbs are used traditionally as blood cleansers and have shown anticancer activity. Use equal parts of the following and take 30 to 60 drops tid. Red clover (Trifolium pratense), blue flag (Iris versicolor), yellowdock (Rumex crispus), poke root (Phytolacca americana), tree of life (Thuja occidentalis), cleavers (Galium aparine), and coneflower (Echinacea purpurea). For late-stage disease, substitute greater celandine (Chelidonium majus) for yellowdock.

Turmeric (Curcuma longa) has been studied and shown to be an antimutagen and antipromotor for cancer. Take 250 to 500 mg bid to tid.

Periwinkle (Vinca rosea), from which vincristine is derived, and autumn primrose (Colchicum officinale), which contains the cytostatic component colchicine, are two toxic herbs to consider for use under a supervising physician.

An experienced homeopath would consider the individual's constitutional type for a more specific remedy and potency. Acute remedies may be useful for symptomatic relief of complications and crises.

Chinese herbs and acupuncture may be a powerful adjunct to conventional therapy.

• Weekly bone marrow biopsies after chemotherapy has begun, to determine an antileukemic effect and normal blood counts or leukemic recurrence
• Daily examinations because infections and bleeding from thrombocytopenia are major reasons for mortality during chemotherapy
• Postremission chemotherapy, to maintain the remission
• Treatment for CNS leukemia for patients with headache, blurred vision, fever, seizures, altered mental state, or cranial nerve palsy
• Uric acid levels, to monitor urinary function

Avoid benzene, nicotine, or radiation exposure, to prevent some leukemias.

• Repeated bacterial (e.g., Klebsiella, Escherichia coli, Pseudomonas, Staphylococcus epidermidis), fungal (e.g., Aspergillus), or viral infections (e.g., herpes zoster) complicate most cases of leukemia. Bleeding is often a presenting complaint.
• Complications of BMT: graft-vs.-host disease, leukemic relapse, and interstitial pneumonitis
• Complications specific to AML: leukostasis (a medical emergency), appendicitis, neutropenic enterocolitis, renal failure, and chloroma
• Complications specific to ALL: CNS leukemia (5% to 10% of patients) and acute tumor lysis syndrome, resulting in hyperuricemia, elevated lactic acid, impaired renal function, and a large tumor burden
• Complications specific to CML: neutropenia as a result of busulfan therapy
• Complication specific to daunorubicin: myelosuppression resulting in pancytopenia

Untreated ANL results in death within two months. Remission can be induced in 75% of patients, but five-year disease-free survival is only 20% to 25%. Five-year survival for ALL is 35% to 45%, remission rates are 60% to 90%, and long-time survival is 40%; it is the most curable form of leukemia. Prognosis for CML is poor although BMT may cure a small percentage of patients. Survival averages three to four years after diagnosis; less than 30% of patients live five years. Prognosis for early stage CLL is 10 to 12 years and late stage, one to two years.

The incidence of leukemia complicating a pregnancy is approximately 1 in 75,000. Women often succumb to their disease after their pregnancy; perinatal outcome is generally poor with increased incidences of fetal death, preterm delivery, and stillbirths. Treatment should not be delayed. Pregnancy termination may be considered during first trimester when chemotherapeutic agents are teratogenic.

Cunningham FG, et al. Williams Obstetrics. 19th ed. Norwalk, Conn: Appleton & Lange; 1993:1270-1272.

DeVita VT Jr, et al. Cancer: Principles and Practice of Oncology. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:2293-2338.

Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:685-694.

Holleb AI, et al. American Cancer Society Textbook of Clinical Oncology. Atlanta, Ga. American Cancer Society; 1991: 410-432.

Kelly WN. Textbook of Internal Medicine. Vol 1. 3rd ed. Philadelphia, Pa: Lippincott-Raven; 1997:

1370-1381.

Wittes RE. Manual of Oncologic Therapeutics. Philadelphia, Pa: Lippincott; 1990: 345-366.

Woodley M. Manual of Medical Therapeutics. 27th ed. Boston, Mass: Little, Brown; 1992:360-361.